A 2-stage exploratory method was used to develop intergenerational dialogue prototypes for the gamification-based intervention and to evaluate its effectiveness on the communication process. Gamification was adopted to incorporate game-based intervention elements such as points, leaderboards, and badges into a nongame context to enhance the engagement experience [22]. This study investigated the effectiveness of the “Healthy Aging in Dialogue Card Game” on intergenerational communication, health, and game experience in three age cohorts: 18‐39 years, 40‐64 years, and ≥65 years. The objectives were to evaluate communication skills (communication competence and satisfaction), health literacy, self-efficacy, and engagement in the game (fun, encouragement to communicate, health knowledge building, and satisfaction) across age groups in the pre- and postsurveys.

Intergenerational communication was assessed in terms of communication satisfaction and communication competence. Communication satisfaction was assessed using four conceptually relevant items selected from Hecht Interpersonal Communication Satisfaction Inventory [35]. The item “I felt I could talk about topic with the other person” was modified from “anything” to “topic” to fit the structured dialogue context, while the remaining three items—“I am generally satisfied with the conversations,” “I enjoy the conversations,” and “These conversations flow smoothly”—were directly adopted. All items were rated on a 6-point Likert scale ranging from “1=extremely disagree” to “6=extremely agree.” Communication competence was evaluated using 6 selected items from the Interpersonal Communication Competence Scale (ICCS) [36], reflecting perspective-taking, emotional awareness, conversational flow, topic management, and sensitivity to nonverbal cues: (1) I can put myself in others’ shoes, (2) I do not know exactly what others are feeling, (3) other people think that I understand them, (4) my conversations are characterized by smooth shifts from one topic to the next, (5) I take charge of conversations I am in by negotiating what topics we talk about, and (6) in conversations, I perceive not only what others say but also what they do not say. Responses were rated on a 4-point Likert scale ranging from “1=extremely disagree” to “4=extremely agree.”

A quantitative analysis of the survey responses was conducted using IBM SPSS (version 29.0). Sample characteristics were reported as descriptive statistics. Items related to intergenerational communication satisfaction, communication competence, health literacy, and the patient enablement index were summed to yield total scores, whereas paired t tests were performed to detect significant changes in target outcomes with 95% CIs. Subgroup analyses by age group were further conducted to examine the impact of the card game across different generations. Cohen d of the three target outcomes (intergenerational communication satisfaction, communication competence, and health literacy) was computed using the mean difference before and after the intervention to evaluate the effect sizes, and Hedges correction was applied for subgroups with n<20 [41]. Effect sizes were considered small, medium, and large with cutoffs of 0.2, 0.5, and 0.8, respectively [41,42]. Findings related to key game experience components, including “fun to play,” “encourage intergenerational communication,” “enhance health knowledge,” and “satisfied with board game question and mission design,” were first presented descriptively. To further examine the associations between the key game experience components and the likelihood of reporting higher levels of overall satisfaction and game engagement, multivariate binary logistic regression models were conducted. For these analyses, the original Likert-scale or continuous scale outcome variables were dichotomized into “higher” vs “lower” satisfaction or engagement. A higher level of satisfaction was defined as a response of “strongly agree” on the 4-point Likert satisfaction scale, while a higher level of engagement was defined as a score of 9‐10 on the 0‐10 engagement scale. The reported odds ratios (ORs) and corresponding 95% CIs were adjusted for age group in the models. A P value of <.05 was considered statistically significant.

Audiotapes recorded during the qualitative sessions were transcribed verbatim, and the transcripts were managed with Microsoft Excel. Experiences related to the game in three aspects, including intergenerational communication, health-related capacity, and overall playing experience, were identified by thematic analysis. The themes and quotes were identified with reference to the discussion guide, and the transcripts were coded twice by 2 independent reviewers to develop the study codebook. With the emergent and recurrent themes identified from the transcripts, these codes were checked and discussed among the independent reviewers to enhance consistency throughout the analysis. Codes were discussed among the research team in case of disagreements. Excerpts were quoted to illustrate the findings uncovered from the qualitative phase.

The tabletop game intervention is a component of a social isolation project approved by the Chinese University of Hong Kong Survey and Behavioral Research Ethics Committee (SBRE-21‐0870). Before the game intervention, informed consent was obtained from participants for participation in the game, surveys, qualitative interviews, and audiotaping.

A total of 81 participants were enrolled in the tabletop game, and 68 completed the intervention and evaluations, yielding a response rate of 84%. A total of 19 game groups were arranged, each involving 3‐5 participants with at least 1 participant from each of 3 age groups. Participants were distributed across the 3 age groups (Table 1). The majority of participants were female (82.4%), living with others (61.8%), had a tertiary education level or above (55.4%), were single (47.1%), and had no religious belief (52.9%). About half of the participants reported having a communicable disease (48.5%). After the intervention and post survey, 52 of 68 (76.5%) participants were interviewed in 8 focus groups and 3 individual interviews. Only 1 focus group was mixed-aged, and 3 individual interviews were arranged due to the unavailability to join the focus group. There was no difference in the direction or richness of sharing; therefore, all focus groups and individual interviews were combined for data analysis. Regarding the characteristics of the interviewees across the 3 age groups, a higher proportion with tertiary education, who were single, who had no religious belief, and who had no chronic disease was observed among the youth, while a higher proportion living alone and being widowed or divorced was observed in the middle-aged and older adult groups. The majority of participants were female (80.8%) across all 3 age groups.

There was a significant improvement in the participants’ self-ratings of communication satisfaction, with a mean difference of −2.76 (95% CI −3.66 to −1.87; Table 2). Participants across all 3 age groups showed significant improvement after the intervention, with mean differences of −2.52 in young adults, −3.93 in middle-aged adults, and −2.42 in older adults. The largest effect size was observed in the middle-aged group (Cohen d=1.13). For participants’ ratings of communication competence, significant improvement was also observed after the intervention, with a mean difference of −1.04 (95% CI −1.71 to −0.37). Improvement was shown across all 3 age groups, but statistically significant improvement was observed only among older adults, with a mean difference of −1.32 (95% CI −2.52 to 0.12). Comparing the 2 communication dimensions, a larger effect size was observed for communication satisfaction (medium effect size of 0.75) than in communication competence (small effect size of 0.38) after the intervention.

Qualitative interviews supported these quantitative findings, showing that the intervention facilitated easier and more relaxed communication.

A young participant remarked:

A middle-aged participant further added:

An older adult participant also shared:

Health literacy significantly improved after the intervention (Table 3). Across the 3 age groups, significant improvements in health literacy with a significant result were observed in the middle-aged (mean difference −0.86, 95% CI −1.60 to −0.11) and older adult groups (mean difference −1.19, 95% CI −1.96 to −0.43) but not in the youth group (mean difference −0.13, 95% CI −0.88 to 0.62). Focusing on the patient enablement effect of the tabletop game intervention, PEI scores significantly increased (Table 3). A comparison of results across the 3 age groups showed that older adults’ PEI (mean 6.10, SD 2.18) was significantly higher than that of the young adult group (mean 4.22, SD 2.59). However, no significant difference was observed in the other comparisons. Details of the comparisons are tabulated in Table 2.

Qualitative data corroborated these results, and a young participant indicated the benefits of the intervention in enhancing health literacy, particularly regarding mental health:

A middle-aged participant highlighted:

An older adult participant shared the impact of health literacy:

In terms of patient enablement, a young participant noted:

A middle-aged participant also mentioned:

An older adult participant expressed:

A strong positive experience with the tabletop game was revealed, with responses heavily inclined toward “agree” and “extremely agree” in all 4 aspects of game experience. The highest proportion of participants found that the tabletop game could encourage intergenerational communication, with 51.5% strongly agreeing, followed by “fun to play” (44.1%), “satisfied with mission card design” (30.9%), and “enhanced our health knowledge” (26.5%). The 4 aspects of game experience are reported in Table 4. The association between game experience and engagement, and overall satisfaction is reported in Table 5. It was found that “encourage intergenerational communication” (OR 4.49, 95% CI 1.09 to 18.58) was significantly associated with participants’ engagement in the tabletop game, whereas “encourage intergenerational communication” (OR 6.22, 95% CI 1.03 to 37.37) and “satisfied with mission card design” (OR 10.20, 95% CI 1.46 to 71.37) were significantly associated with the overall satisfaction of the tabletop game.

Regarding the qualitative findings, participants emphasized the opportunities this game offered for intergenerational interaction. For example, one young participant mentioned:

An older adult participant further added:

In addition, a young participant expressed enjoyment of the game:

A middle-aged participant also commented on the game’s enjoyable nature:

An older adult participant reflected on the intergenerational engagement:

The game’s design was recognized as a key factor in its success. A young participant mentioned:

A middle-aged participant also expressed satisfaction with the game design:

An older adult participant also acknowledged the game design:

This intergenerational intervention yielded notable benefits in intergenerational communication, health literacy, and patient empowerment, especially for older adults. While the majority of gamification interventions for older adults have focused on evaluating the impact on health outcomes [43], the current evaluation provides a comprehensive review of communication and health-related outcomes. In addition, this study highlighted the importance of leveraging gamification to enhance intergenerational communication and ultimately combat social isolation among older adults.

Across all age groups, participants reported significantly higher communication satisfaction post intervention, indicating that the game fostered enjoyable and fulfilling dialogue. While short-term increases in communication satisfaction following an engaging activity are, to some extent, expected and may partly reflect novelty or positive study participation effects, communication satisfaction reflects perceived interaction quality rather than transient mood alone. In this intervention, satisfaction was fostered through structured dialogue, guided turn-taking, and role rotation, which targeted communication processes that can plausibly generalize beyond the immediate gameplay context. Nevertheless, sustained effects cannot be inferred from the present design and require confirmation through longitudinal follow-up. Notably, only older adults showed a significant improvement in their communication competence scores, whereas younger and middle-aged adults did not. One explanation lies in baseline differences: older participants may have had fewer opportunities for rich social interaction before the study due to the prevalence of social isolation among Hong Kong’s older population. Indeed, as of 2021, nearly 190,000 adults aged 65 years and older were living alone in Hong Kong, reflecting a 60% increase since 2011 [44]. Such isolation is linked to declines in communication skills and cognitive function [45]. By facilitating regular, meaningful conversations, the game likely helped older participants practice and regain communication competencies. This aligns with evidence that increasing social interaction can improve older adults’ performance on verbal communication tasks [46]. In contrast, younger adults—who typically have more daily social communication—may have been closer to a ceiling in communication ability, limiting observable gains.

Differential effects on health literacy were also observed. Middle-aged and older participants showed significant improvements in health literacy after gameplay, whereas the youth group did not. Younger adults likely entered the study with higher baseline health literacy, given their greater exposure to education and digital information, and thus had less room for measurable improvement. Older adults, on the other hand, often start with lower health literacy and greater health knowledge gaps. The game’s health literacy module provided an engaging, accessible means of learning health information, resulting in tangible knowledge gains for these groups. This finding is consistent with prior research showing that game-based interventions can substantially increase health-related knowledge [47]. Moreover, intergenerational learning theory suggests that structured dialogue between generations creates opportunities for mutual education and attitude change [48]. During the health literacy tasks, younger players might have shared digital health information or taught health concepts, benefiting their older counterparts. Reciprocally, older adults may have shared personal health experiences, which could enrich understanding for young and middle-aged adults. The middle-aged group, interestingly, also improved in health literacy, suggesting that those in midlife, often caring for both children and older adult parents, found the health knowledge and cross-generational communication practice directly relevant and empowering for their caregiving and self-care roles.

Importantly, the older group showed a significantly higher PEI score post intervention than the youth group, with no significant differences between the other groups. The high PEI score in older adults suggests that the game may have enhanced their confidence and sense of “enablement” in dealing with health issues. Several mechanisms could explain this. First, older participants likely felt a sense of accomplishment and agency by contributing actively to group tasks, such as sharing life experiences or completing challenges. Being listened to by younger peers may have bolstered their self-esteem and sense of purpose, which, according to Socioemotional Selectivity Theory, is highly valued in late life [49]. The theory posits that as people age and perceive a shorter future time horizon, they prioritize meaningful social interactions and emotional fulfillment. Importantly, this does not imply that brief interactions with unfamiliar partners function as strong-tie relationships; rather, the intervention may have uncovered interaction contexts characterized by emotional affirmation, mutual respect, and psychological safety, which align with the socioemotional qualities prioritized in later life. In our study, the older adults’ disproportionate gains in communication ability and health literacy could be a good start toward confidence-building in intergenerational interaction and a strong sense of enablement. Moreover, the opportunity to impart wisdom and bond with younger people likely fulfilled older adults’ socioemotional goals, thereby maximizing their engagement and leading to greater gains from the program. In contrast, younger participants generally have a more future-oriented outlook and myriad social connections; while they enjoyed the game, as evidenced by improved satisfaction, they may not have experienced the same degree of program gains or personal empowerment.

The outcome was a unanimous perception across all age groups that the game strengthened intergenerational communication and was well-designed, fun, and educational. These positive subjective evaluations are noteworthy given the challenge of designing content appealing to diverse ages. By using gamification—points, challenges, and playful interactions—the intervention kept participants intrinsically motivated. Gamification theory holds that introducing game elements into nongame contexts (such as health education) can enhance user engagement and motivation [50]. Consistently, our findings show high engagement and satisfaction scores, indicating that the game format was indeed engaging. Prior studies in older adults have also found that appropriately designed card games can acutely boost mood and well-being during play [51]. Our intergenerational game seems to have capitalized on these effects, creating an enjoyable learning environment that felt less like a health workshop and more like a social gathering.

The association analyses provide further insight into what drove the intervention’s success. We found that participants who felt the game “encouraged intergenerational communication” were significantly more likely to report higher engagement in the activities and greater overall satisfaction, reinforcing the importance of perceived interaction quality as a proximal outcome. In other words, when players perceived that the core purpose of the game, bridging generations, was being achieved, their involvement and satisfaction were maximized. This underscores the importance of making the intergenerational benefits salient—participants who recognized the value in connecting with other ages likely invested more effort and attention, potentially creating a virtuous cycle of engagement and positive experience. We also found that satisfaction with the game design was strongly correlated with overall satisfaction. This highlights the role of user-centered design, encompassing elements such as clear rules, culturally relevant content, and balanced difficulty across modules, which likely enhanced enjoyment. From a gamification perspective, well-designed game mechanics (eg, rotating tasks, creative challenges, and immediate feedback through group discussion) can fulfill psychological needs such as autonomy, competence, and relatedness, leading to higher satisfaction [52].

First, although the inclusion criteria were broad, participants voluntarily enrolled in the intervention, and the majority were female, which may not be representative of all eligible individuals; selection bias may therefore limit generalizability. However, the qualitative interviews provided in-depth insights that may help inform the design of a larger-scale randomized controlled trial. Second, intergenerational communication outcomes were assessed using selected items from validated instruments rather than the complete scales. While this may limit psychometric completeness, the selected items were purposefully chosen to reflect communicative processes relevant to brief, structured intergenerational interactions within a gamified setting. Accordingly, findings should be interpreted with appropriate caution. Full-length scales include items less applicable to this context, and their use may compromise relevance and participant engagement. Third, some outcomes were dichotomized for analysis due to skewed response distributions, which may have reduced variability and statistical power and potentially obscured differences in participants’ responses. Fourth, the sample size for the middle-aged group was comparatively smaller than that of the other 2 groups, although the minimum sample size requirement was met. This imbalance may have limited statistical power for 3-group comparisons. Finally, a 30-minute game duration was recommended, but this was not implemented strictly to sustain positive game dynamics. Variations in actual game time may influence comparisons across groups. However, these variations may also reflect natural engagement patterns in intergenerational communication settings.

In conclusion, the intergenerational card game intervention in Hong Kong demonstrated an effective approach to enhancing communication satisfaction, health literacy, and health enablement, particularly benefiting older adults in an aging, isolated population. By providing an enjoyable and structured platform for cross-generational dialogue, the game enabled meaningful engagement and mutual learning between age groups, fostering high levels of participant engagement. These findings underscore the potential of playful, socially embedded interventions to complement traditional health care services by addressing psychosocial determinants of health. Given its low cost, scalability, and high acceptability, this approach holds promise as a public health tool in aging societies worldwide. Future research should further examine the tool’s psychometric properties and extend this work through randomized controlled trials or longitudinal studies to assess longer-term impacts on health behaviors, clinical outcomes, and broader dimensions of social connectedness.